Interview: 'Public dental services in South Africa have fallen by the wayside'

Daniel Zimmermann: Prof. Naidoo, very little is known about the current state of oral health in South Africa. Would you describe the current situation for our readers?
Prof. Sudeshni Naidoo: The last National Oral Health Survey was conducted a long time ago, back in 1989/1990. We conducted another survey approx. 10 years later but only on children up to 15 years of age. Therefore, it is really difficult to comment on the oral health situation in South Africa at the moment.

Other research has been documented, of course, for example through the South Africa Demographic and Health Survey in 2003, which interviewed respondents regarding oral health. What we found from these studies is that oral health varies a lot in South Africa, especially between populations in rural and urban areas, where we found significantly higher levels of tooth decay. One of the reasons for this is the migration of a large number of people moving from the rural areas to the big cities after the abolishment of Apartheid in 1994. These peri-urban populations have experienced rapid deterioration in oral health owing to changes in their diet.

I am sure that were we to conduct a survey now, chances are high that the level of decay would still be on the increase.

Early childhood caries (EEC) is one of the major oral health problems in developed and undeveloped countries alike. Is this true in South Africa too?
ECC is a significant problem throughout the country, but especially here in the Western Cape Province, which has the highest rate of children with EEC, also known as ‘rampant caries’. Again, this is related to diet and poor habits. Mothers often feed their children on a diet high in sugars or put large amounts of sugar in feeding bottles. One of the common things we use here, for example, is condensed milk and that often leads to rapid decay.

I have to admit that we have not comprehensively sought for a manner in which to address the problem. One of the things we certainly have to do is integrate oral health messages into the general health messages that are formulated and propagated by the Department of Health.

As far as ECC is concerned, it is imperative for us to cooperate with antenatal clinics and seek to educate mothers and mothers-to-be regarding prevention and the way in which to look after their children’s teeth.

Is oral health awareness generally poor?
To give you an answer to this question, I have to return to the latest South Africa Demographic and Health Survey. In this survey, we found that over 90 per cent of the respondents gave the response “yes” to questions like “Do you have a toothbrush?” or “Do you brush your teeth?”. We were a little bit concerned with this high positive response because we knew from smaller studies that low-income households usually cannot afford toothbrushes or toothpaste, and a single toothbrush are sometimes shared between six or eight family members.

School-based prevention programmes in Asia, for example, have shown promising results for the improvement of personal dental hygiene. Could such programmes be considered a model for South Africa?
Absolutely. However, the problem with implementing these programmes in South Africa is the lack of coordination. Several programmes have already been implemented in various parts of the country in the last few years, but they have not been done so in any uniform way.

During the Apartheid era, we had vertical oral health care programmes and the funding for oral health was ring-fenced. However, after the decentralisation of the health care sector and the introduction of the District Health Care System in the mid 1990s, every province received a budget for general health funding instead of specific programmes and, therefore, oral health services in the public sector have fallen by the wayside.

We really need to start thinking about bringing all these programmes back, particularly with a view to the fact that we have not seen any significant reduction of caries levels in our dental clinics. The experiences of other developing countries with regard to implementation of such programmes could be helpful in this respect.

What other measures should be implemented to improve the situation in South Africa?
Besides poor oral health awareness, our main challenges are the huge disparities in various parts of the country and the gap between the public and private sectors. We have private clinics both in medical and dental care that rival some of the best in Europe and North America. In our public sector, however, we have a long way to go to reach anywhere near the kind of services that you might expect to get in Scandinavia, for example.

At the moment, almost 70 per cent of our population seeks treatment in the public sector and cannot afford the private medical care that is available in the country.

Personally, I do not see the number of oral health care workers drastically increasing in the next five to ten years. So what we need to do is to piggyback on other activities that will help us to enhance and improve the oral health status of people in South Africa, such as linking oral health messages into general health messages and being very actively involved in the general health preventive programmes that are currently being implemented. We also have to convince our medical colleagues that the mouth is the gateway to health and that oral health has an impact on his/her general health and consequently, quality of life.

We also need to revisit our water fluoride legislation. Water fluoridation efforts have been stalled in recent years and even though it is legislated that we incorporate it into our public water supplies, several municipalities have blatantly refused or have been unable to implement water fluoridation measures.

South Africa currently has the highest number of people living with HIV/Aids in the world. What impact does the pandemic have on health care workers in the country?
The HIV/Aids pandemic has indeed had a devastating impact on the public health care sector and has overloaded the health care-workers, including dentists. In some parts of the country it is estimated that up to 75 per cent of our in-patients in public hospitals are there on account of some HIV/Aids-related illness. In addition, South Africa has one of the highest levels of people infected with Tuberculosis, with the centre again being here in the Western Cape Province.

I do not think this is something that is going to go away in the next 10 to 20 years because even though we have improved on the number of people receiving antiretroviral medication, there are still hundreds of thousands of people who are in need but do not have access to it.

Is there sufficient awareness of the disease amongst oral health care workers?
Awareness amongst our health care workers has definitively improved. I think the transition from an HIV/Aids-denialist to a much more open presidency in the past few years has definitely been a positive development. In fact, this month key government officials, including the President underwent HIV/Aids tests, with the results given out in public.

Unfortunately, the reason many oral health care personnel are aware of HIV/Aids is still largely due to risk and the fear of contracting the virus. To my knowledge, however, there is not a single documented case of transmission within a dental setting. What we certainly do here at the UWC Faculty of Dentistry is to tell our students that while the risk is present, it is also miniscule. In addition, they receive a good grounding, not only on prevention measures but also on care and management of patients infected with HIV/Aids, such as detection and management of the oral manifestations of HIV.

There has also been a great focus on the ethical issues related to the management of patients with HIV/AIDS within Continuing Professional Development programmes. Health care workers who want to register with the Health Professions Council, for example, have to prove that they have earned 30 CDP points per year. So I think our oral health care workers are pretty much up to date on these issues.

Thank you very much for this interview.